Methods and compositions for regulating srca2a expression levels in myocardial infarction

ABSTRACT

The disclosure provides methods and compositions for increasing SERCA2a expression levels in a mammalian subject in need thereof. The methods comprise administering to the subject a therapeutic amount of an aromatic-cationic peptide to subjects in need thereof. In some embodiments, the aromatic-cationic peptide is D-Arg-2′6′-Dmt-Lys-Phe-NH2, or a pharmaceutically acceptable salt thereof such as acetate or trifluoroacetate salt. In some embodiments, the subject has suffered a myocardial infarction.

CROSS-REFERENCE TO RELATED APPLICATIONS

This Application claims the benefit of and priority to U.S. ApplicationNo. 61/839,758, filed Jun. 26, 2013, which is incorporated herein byreference in its entirety.

TECHNICAL FIELD

The present technology relates generally to methods of treating orpreventing left ventricular remodeling in a subject in need thereof. Inparticular, the present technology relates to administeringaromatic-cationic peptides in effective amounts to regulate (e.g.,increase) sarco/endoplasmic reticulum Ca2+-ATPase 2a (“SERCA2a”) postmyocardial infarction.

BACKGROUND

The following description is provided to assist the understanding of thereader. None of the information provided or references cited is admittedto be prior art to the present technology.

Following myocardial infarction there is a dynamic and progressive leftventricle (LV) remodeling that contributes to LV dilation, heartfailure, and death. LV remodeling increases LV wall stress, which leadsto an increase in oxygen demand. To help compensate for the loss ofmyocardium and reduced stroke volume, the LV develops global dilationand the non-infarcted wall of the LV develops eccentric hypertrophy. Asthe ventricle dilates, the dilation process initially helps tocompensate for reduced stroke volume. However, eventually progressivedilatation and hypertrophy lead to congestive heart failure. One of thestrongest predictors of death one year post myocardial infarction is thevolume of the left ventricle.

SUMMARY

The present technology relates generally to the normalization (e.g.,increase) of SERCA2a expression by administration of therapeuticallyeffective amounts of aromatic-cationic peptides to subjects in needthereof.

In some aspects, the present technology provides methods for normalizingor stabilizing (e.g., increasing) SERCA2a expression a mammalian subjectin need thereof by administering a therapeutically effective amount anaromatic-cationic peptide.

In some embodiments, the stabilization (e.g., increasing) of SERCA2aexpression prevents, ameliorates, or treats LV remodeling.

In some embodiments, the aromatic-cationic peptide isD-Arg-2′6′-Dmt-Lys-Phe-NH₂, or a pharmaceutically acceptable saltthereof such as acetate or trifluoroacetate salt. In some embodiments,the subject has suffered a myocardial infarction.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 is a graph showing the effect of D-Arg-2′6′-Dmt-Lys-Phe-NH₂ onSERCA2a expression in border zone cells and remote area cells.

FIGS. 2A-2C are graphs showing the effect of D-Arg-2′6′-Dmt-Lys-Phe-NH₂on left ventricle fractional shortening.

FIG. 3A is a graph showing the effect of D-Arg-2′6′-Dmt-Lys-Phe-NH₂ onleft ventricle stroke volume.

FIG. 3B is a graph showing the effect of D-Arg-2′6′-Dmt-Lys-Phe-NH₂ onleft ventricle ejection fraction.

FIG. 4 is a graph showing the effect of D-Arg-2′6′-Dmt-Lys-Phe-NH₂ onpost-mortem LV volume.

FIGS. 5A-5C are graphs showing the effect of D-Arg-2′6′-Dmt-Lys-Phe-NH₂on LV non-scar and scar circumference.

FIG. 6 is a graph showing that D-Arg-2′6′-Dmt-Lys-Phe-NH₂ reduces LVvolume/heart weight.

DETAILED DESCRIPTION

It is to be appreciated that certain aspects, modes, embodiments,variations and features of the technology are described below in variouslevels of detail in order to provide a substantial understanding of thepresent technology. The definitions of certain terms as used in thisspecification are provided below. Unless defined otherwise, alltechnical and scientific terms used herein generally have the samemeaning as commonly understood by one of ordinary skill in the art towhich this technology belongs.

As used in this specification and the appended claims, the singularforms “a”, “an” and “the” include plural referents unless the contentclearly dictates otherwise. For example, reference to “a cell” includesa combination of two or more cells, and the like.

As used herein, the “administration” of an agent, drug, or peptide to asubject includes any route of introducing or delivering to a subject acompound to perform its intended function. Administration can be carriedout by any suitable route, including orally, intranasally, parenterally(intravenously, intramuscularly, intraperitoneally, or subcutaneously),or topically. Administration includes self-administration and theadministration by another.

As used herein, the term “amino acid” includes naturally-occurring aminoacids and synthetic amino acids, as well as amino acid analogs and aminoacid mimetics that function in a manner similar to thenaturally-occurring amino acids. Naturally occurring amino acids arethose encoded by the genetic code, as well as those amino acids that arelater modified, e.g., hydroxyproline, γ-carboxyglutamate, andO-phosphoserine. Amino acid analogs refers to compounds that have thesame basic chemical structure as a naturally-occurring amino acid, i.e.,an α-carbon that is bound to a hydrogen, a carboxyl group, an aminogroup, and an R group, e.g., homoserine, norleucine, methioninesulfoxide, methionine methyl sulfonium. Such analogs have modified Rgroups (e.g., norleucine) or modified peptide backbones, but retain thesame basic chemical structure as a naturally occurring amino acid. Aminoacid mimetics refers to chemical compounds that have a structure that isdifferent from the general chemical structure of an amino acid, but thatfunctions in a manner similar to a naturally occurring amino acid. Aminoacids can be referred to herein by either their commonly known threeletter symbols or by the one-letter symbols recommended by the IUPAC-IUBBiochemical Nomenclature Commission.

As used herein, the term “border zone cells” refers to cardiac cellsthat border, surround, or lie in close proximity to an infarct zone in aheart. In some embodiments, the border zone is a strip of non-infarctedheart tissue about 2 mm in width surrounding the scar. Border zone cellsare the cardiac cells that are subject to left ventricular remodeling,as the border zone cells compensate for the necrotic cardiac tissueresulting from the infarct.

As used herein, the term “remote cells” refers to cardiac cells beyondthe border zone cells. These cells lie farther away from the infarctzone and normally remain unaffected from the infarction.

As used herein, the term “control” has its customary meaning in the art,and can refer to e.g., cells, such as border zone cells or remote cells,that are not treated with a therapeutic agent or test agent, e.g., suchan aromatic-cationic peptide. Controls can be used, as is known in theart, as “standards” to ascertain the effect of a particular treatment.For example, control (untreated) border zone cells and remote cells canbe used to determine the effect of aromatic-cationic peptide treatmenton border zone cells and remote cells.

As used herein, the term “effective amount” refers to a quantitysufficient to achieve a desired therapeutic and/or prophylactic effect,e.g., an amount that results in the stabilization (e.g., increase) ofSERCA2a expression. Additionally, as used herein, effective amount canrefer to a quantity that results in a prevention of, or a decrease in,LV remodeling or one or more symptoms associated with LV remodeling. Inthe context of therapeutic or prophylactic applications, the amount of acomposition administered to the subject will depend on the type andseverity of the disease and on the characteristics of the individual,such as general health, age, sex, body weight and tolerance to drugs. Itwill also depend on the degree, severity and type of disease. Theskilled artisan will be able to determine appropriate dosages dependingon these and other factors.

As used herein, the term “left ventricle (LV) remodeling” has itscustomary meaning known in the art and refers to a condition typicallycharacterized by increasing LV wall stress and increasing oxygen demand.LV remodeling may also include LV dilation and the development ofeccentric hypertrophy in the non-infarct cardiac cells of the LV. Duringthis process, sarcomeres are added on in a circumferential or lengthwisefashion. As the ventricle dilates this process initially helps tocompensate for reduced stroke volume, but eventually progressivedilatation and hypertrophy lead to congestive heart failure. One of thestrongest predictors of death one year post myocardial infarction is thevolume of the left ventricle. The more dilated, the greater the chanceof death. The signs of LV remodeling include, but are not limited to:reduced LV stroke volume, reduced LV ejection fraction, poor fractionalshortening, increased infarct expansion, poor hemodynamics, increasedscar formation in LV myocardium, and increased lung volumes.

An used herein, the terms “isolated” or “purified” polypeptide orpeptide refers to polypeptides or peptides substantially free ofcellular material or other contaminating polypeptides from the cell ortissue source from which the agent is derived, or substantially freefrom chemical precursors or other chemicals when chemically synthesized.For example, an isolated aromatic-cationic peptide would be free ofmaterials that would interfere with diagnostic or therapeutic uses ofthe agent. Such interfering materials may include enzymes, hormones andother proteinaceous and nonproteinaceous solutes.

As used herein, “net charge” refers to the balance of the number ofpositive charges and the number of negative charges carried by the aminoacids present in the peptide. In this specification, it is understoodthat net charges are measured at physiological pH. The naturallyoccurring amino acids that are positively charged at physiological pHinclude L-lysine, L-arginine, and L-histidine. The naturally occurringamino acids that are negatively charged at physiological pH includeL-aspartic acid and L-glutamic acid.

As used herein, the term “pharmaceutically acceptable salt” refers asalt prepared from a base or an acid which is acceptable foradministration to a patient, such as a mammal (e.g., salts havingacceptable mammalian safety for a given dosage regime). However, it isunderstood that the salts are not required to be pharmaceuticallyacceptable salts, such as salts of intermediate compounds that are notintended for administration to a patient. Pharmaceutically acceptablesalts can be derived from pharmaceutically acceptable inorganic ororganic bases and from pharmaceutically acceptable inorganic or organicacids. In addition, when a peptide contains both a basic moiety, such asan amine, pyridine or imidazole, and an acidic moiety such as acarboxylic acid or tetrazole, zwitterions may be formed and are includedwithin the term “salt” as used herein.

As used herein the term “pharmaceutically acceptable carrier” includessaline, solvents, dispersion media, coatings, antibacterial andantifungal agents, isotonic and absorption delaying agents, and thelike, compatible with pharmaceutical administration.

As used herein, the terms “polypeptide,” “peptide,” and “protein” areused interchangeably herein to mean a polymer comprising two or moreamino acids joined to each other by peptide bonds or modified peptidebonds, i.e., peptide isosteres. Polypeptide refers to both short chains,commonly referred to as peptides, glycopeptides or oligomers, and tolonger chains, generally referred to as proteins. Polypeptides maycontain amino acids other than the 20 gene-encoded amino acids.Polypeptides include amino acid sequences modified either by naturalprocesses, such as post-translational processing, or by chemicalmodification techniques that are well known in the art.

As used herein, the term “simultaneous” therapeutic use refers to theadministration of at least two active ingredients by the same route andat the same time or at substantially the same time.

As used herein, the term “separate” therapeutic use refers to anadministration of at least two active ingredients at the same time or atsubstantially the same time by different routes.

As used herein, the term “sequential” therapeutic use refers toadministration of at least two active ingredients at different times,the administration route being identical or different. Moreparticularly, sequential use refers to the whole administration of oneof the active ingredients before administration of the other or otherscommences. It is thus possible to administer one of the activeingredients over several minutes, hours, or days before administeringthe other active ingredient or ingredients. There is no simultaneoustreatment in this case.

As used herein, the term “stabilize” or “stabilizing” in regards to geneexpression (e.g., SERCA2a expression) refers to maintaining, normalizingor regaining gene expression levels (e.g., RNA or protein levels) incells, such as border zone or remote infarct cardiac cells, to about thesame level of expression as non-infarct normal cardiac cells. Forexample, as disclosed herein, administration of an aromatic-cationicpeptide to subjects with reduced SERCA2a levels results in the subjecthaving increased SERCA2a levels as compared to untreated controlsubjects. In some embodiments, administration of an aromatic-cationicpeptide to a subject susceptible to or suffering from a disease orcondition characterized by low SERCA2a levels results in the subjecthaving higher SERCA2a levels (e.g., less reduction in SERCA2a expressionlevels) than an untreated control subject.

As used herein, the terms “treating,” “treatment,” or “alleviation”refers to therapeutic treatment, wherein the object is to reduce or slowdown (lessen) the targeted pathologic condition or disorder. Forexample, a subject is successfully “treated” for LV remodeling if, afterreceiving a therapeutic amount of the aromatic-cationic peptidesaccording to the methods described herein, the subject shows observableand/or measurable reduction in or absence of (e.g., a physiologicalimprovement of) one or more signs and symptoms of LV remodeling, suchas, e.g., reduced LV stroke volume, reduced LV ejection fraction, poorfractional shortening, increased infarct expansion, poor hemodynamics,increased scar formation in LV myocardium, myocardial stretching andthinning, and increased lung volumes. It is also to be appreciated thatthe various modes of treatment or prevention of medical conditions asdescribed are intended to mean “substantial,” which includes total butalso less than total treatment or prevention, and wherein somebiologically or medically relevant result is achieved. Treating LVremodeling, as used herein, also refers to the increase or preventingthe decease of mitochondrial biogenesis. In some embodiments, treatingLV remodeling includes increasing expression levels of SERCA2a (e.g.,RNA and/or protein levels) and/or activity in a subject in need thereof.

As used herein, “prevention” or “preventing” of a disorder or conditionrefers to a compound that, in a statistical sample, reduces theoccurrence of the disorder or condition in the treated sample relativeto an untreated control sample, or delays the onset of one or moresymptoms of the disorder or condition relative to the untreated controlsample. As used herein, preventing LV remodeling includes preventing theinitiation of LV remodeling, delaying the initiation of LV remodeling,preventing the progression or advancement of LV remodeling, slowing theprogression or advancement of LV remodeling, and delaying theprogression or advancement of LV remodeling. In some embodiments,preventing LV remodeling includes increasing expression levels ofSERCA2a (e.g., RNA and/or protein levels) and/or activity in a subjectin need thereof.

As used herein, the term “chronic,” with reference to administration,refers to administration of a therapeutic agent, such as anaromatic-cationic peptide, for about 3 days, about 4 days, about 5 days,about 6 days, about 1 week, about 2 weeks, about 3 weeks, 4 weeks, 5weeks 6 weeks, about 2 months, about 3 months, about 6 months, about 9months, about 1 year or longer. In some embodiments, chronicadministration includes administration once per day, twice per day, 3-5times per day, every other day, every third day, once per week or onceper month.

Aromatic-Cationic Peptides

The present technology relates to the stabilization of SERCA2aexpression and related conditions by administration of certainaromatic-cationic peptides. The aromatic-cationic peptides arewater-soluble and highly polar. Despite these properties, the peptidescan readily penetrate cell membranes. The aromatic-cationic peptidestypically include a minimum of three amino acids or a minimum of fouramino acids, covalently joined by peptide bonds. The maximum number ofamino acids present in the aromatic-cationic peptides is about twentyamino acids covalently joined by peptide bonds. Suitably, the maximumnumber of amino acids is about twelve, more preferably about nine, andmost preferably about six.

The amino acids of the aromatic-cationic peptides can be any amino acid.The amino acids may be naturally occurring. Naturally occurring aminoacids include, for example, the twenty most common levorotatory (L)amino acids normally found in mammalian proteins, i.e., alanine (Ala),arginine (Arg), asparagine (Asn), aspartic acid (Asp), cysteine (Cys),glutamine (Gln), glutamic acid (Glu), glycine (Gly), histidine (His),isoleucine (Ile), leucine (Leu), lysine (Lys), methionine (Met),phenylalanine (Phe), proline (Pro), serine (Ser), threonine (Thr),tryptophan, (Trp), tyrosine (Tyr), and valine (Val). Other naturallyoccurring amino acids include, for example, amino acids that aresynthesized in metabolic processes not associated with proteinsynthesis. For example, the amino acids ornithine and citrulline aresynthesized in mammalian metabolism during the production of urea.Another example of a naturally occurring amino acid includeshydroxyproline (Hyp).

The peptides optionally contain one or more non-naturally occurringamino acids. Optimally, the peptide has no amino acids that arenaturally occurring. The non-naturally occurring amino acids may belevorotary (L-), dextrorotatory (D-), or mixtures thereof. Non-naturallyoccurring amino acids are those amino acids that typically are notsynthesized in normal metabolic processes in living organisms, and donot naturally occur in proteins. In addition, the non-naturallyoccurring amino acids suitably are also not recognized by commonproteases. The non-naturally occurring amino acid can be present at anyposition in the peptide. For example, the non-naturally occurring aminoacid can be at the N-terminus, the C-terminus, or at any positionbetween the N-terminus and the C-terminus.

The non-natural amino acids may, for example, comprise alkyl, aryl, oralkylaryl groups not found in natural amino acids. Some examples ofnon-natural alkyl amino acids include α-aminobutyric acid,β-aminobutyric acid, γ-aminobutyric acid, δ-aminovaleric acid, andε-aminocaproic acid. Some examples of non-natural aryl amino acidsinclude ortho-, meta, and para-aminobenzoic acid. Some examples ofnon-natural alkylaryl amino acids include ortho-, meta-, andpara-aminophenylacetic acid, and γ-phenyl-β-aminobutyric acid.Non-naturally occurring amino acids include derivatives of naturallyoccurring amino acids. The derivatives of naturally occurring aminoacids may, for example, include the addition of one or more chemicalgroups to the naturally occurring amino acid.

For example, one or more chemical groups can be added to one or more ofthe 2′, 3′, 4′, 5′, or 6′ position of the aromatic ring of aphenylalanine or tyrosine residue, or the 4′, 5′, 6′, or 7′ position ofthe benzo ring of a tryptophan residue. The group can be any chemicalgroup that can be added to an aromatic ring. Some examples of suchgroups include branched or unbranched C₁-C₄ alkyl, such as methyl,ethyl, n-propyl, isopropyl, butyl, isobutyl, or t-butyl, C₁-C₄ alkyloxy(i.e., alkoxy), amino, C₁-C₄ alkylamino and C₁-C₄ dialkylamino (e.g.,methylamino, dimethylamino), nitro, hydroxyl, halo (i.e., fluoro,chloro, bromo, or iodo). Some specific examples of non-naturallyoccurring derivatives of naturally occurring amino acids includenorvaline (Nva) and norleucine (Nle).

Another example of a modification of an amino acid in a peptide is thederivatization of a carboxyl group of an aspartic acid or a glutamicacid residue of the peptide. One example of derivatization is amidationwith ammonia or with a primary or secondary amine, e.g., methylamine,ethylamine, dimethylamine or diethylamine. Another example ofderivatization includes esterification with, for example, methyl orethyl alcohol. Another such modification includes derivatization of anamino group of a lysine, arginine, or histidine residue. For example,such amino groups can be acylated. Some suitable acyl groups include,for example, a benzoyl group or an alkanoyl group comprising any of theC₁-C₄ alkyl groups mentioned above, such as an acetyl or propionylgroup.

The non-naturally occurring amino acids are suitably resistant orinsensitive to common proteases. Examples of non-naturally occurringamino acids that are resistant or insensitive to proteases include thedextrorotatory (D-) form of any of the above-mentioned naturallyoccurring L-amino acids, as well as L- and/or D-non-naturally occurringamino acids. The D-amino acids do not normally occur in proteins,although they are found in certain peptide antibiotics that aresynthesized by means other than the normal ribosomal protein syntheticmachinery of the cell. As used herein, the D-amino acids are consideredto be non-naturally occurring amino acids.

In order to minimize protease sensitivity, the peptides should have lessthan five, preferably less than four, more preferably less than three,and most preferably, less than two contiguous L-amino acids recognizedby common proteases, irrespective of whether the amino acids arenaturally or non-naturally occurring. Optimally, the peptide has onlyD-amino acids, and no L-amino acids. If the peptide contains proteasesensitive sequences of amino acids, at least one of the amino acids ispreferably a non-naturally-occurring D-amino acid, thereby conferringprotease resistance. An example of a protease sensitive sequenceincludes two or more contiguous basic amino acids that are readilycleaved by common proteases, such as endopeptidases and trypsin.Examples of basic amino acids include arginine, lysine and histidine.

The aromatic-cationic peptides should have a minimum number of netpositive charges at physiological pH in comparison to the total numberof amino acid residues in the peptide. The minimum number of netpositive charges at physiological pH will be referred to below as(p_(m)). The total number of amino acid residues in the peptide will bereferred to below as (r). The minimum number of net positive chargesdiscussed below are all at physiological pH. The term “physiological pH”as used herein refers to the normal pH in the cells of the tissues andorgans of the mammalian body. For instance, the physiological pH of ahuman is normally approximately 7.4, but normal physiological pH inmammals may be any pH from about 7.0 to about 7.8.

Typically, an aromatic-cationic peptide has a positively chargedN-terminal amino group and a negatively charged C-terminal carboxylgroup. The charges cancel each other out at physiological pH. As anexample of calculating net charge, the peptideTyr-Arg-Phe-Lys-Glu-His-Trp-D-Arg has one negatively charged amino acid(i.e., Glu) and four positively charged amino acids (i.e., two Argresidues, one Lys, and one His). Therefore, the above peptide has a netpositive charge of three.

In one embodiment, the aromatic-cationic peptides have a relationshipbetween the minimum number of net positive charges at physiological pH(p_(m)) and the total number of amino acid residues (r) wherein 3p_(m)is the largest number that is less than or equal to r+1. In thisembodiment, the relationship between the minimum number of net positivecharges (p_(m)) and the total number of amino acid residues (r) is asfollows:

TABLE 1 Amino acid number and net positive charges (3p_(m) ≤ p + 1) (r)3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 (p_(m)) 1 1 2 2 2 3 3 3 44 4 5 5 5 6 6 6 7

In another embodiment, the aromatic-cationic peptides have arelationship between the minimum number of net positive charges (p_(m))and the total number of amino acid residues (r) wherein 2p_(m) is thelargest number that is less than or equal to r+1. In this embodiment,the relationship between the minimum number of net positive charges(p_(m)) and the total number of amino acid residues (r) is as follows:

TABLE 2 Amino acid number and net positive charges (2p_(m) ≤ p + 1) (r)3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 (p_(m)) 2 2 3 3 4 4 5 5 66 7 7 8 8 9 9 10 10

In one embodiment, the minimum number of net positive charges (p_(m))and the total number of amino acid residues (r) are equal. In anotherembodiment, the peptides have three or four amino acid residues and aminimum of one net positive charge, suitably, a minimum of two netpositive charges and more preferably a minimum of three net positivecharges.

It is also important that the aromatic-cationic peptides have a minimumnumber of aromatic groups in comparison to the total number of netpositive charges (p_(t)). The minimum number of aromatic groups will bereferred to below as (a). Naturally occurring amino acids that have anaromatic group include the amino acids histidine, tryptophan, tyrosine,and phenylalanine. For example, the hexapeptideLys-Gln-Tyr-D-Arg-Phe-Trp has a net positive charge of two (contributedby the lysine and arginine residues) and three aromatic groups(contributed by tyrosine, phenylalanine and tryptophan residues).

The aromatic-cationic peptides should also have a relationship betweenthe minimum number of aromatic groups (a) and the total number of netpositive charges at physiological pH (p_(t)) wherein 3a is the largestnumber that is less than or equal to p_(t)+1, except that when p_(t) is1, a may also be 1. In this embodiment, the relationship between theminimum number of aromatic groups (a) and the total number of netpositive charges (p_(t)) is as follows:

TABLE 3 Aromatic groups and net positive charges (3a ≤ p_(t) + 1 or a =p_(t) = 1) (p_(t)) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20(a) 1 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 6 6 6 7

In another embodiment, the aromatic-cationic peptides have arelationship between the minimum number of aromatic groups (a) and thetotal number of net positive charges (p_(t)) wherein 2a is the largestnumber that is less than or equal to p_(t)+1. In this embodiment, therelationship between the minimum number of aromatic amino acid residues(a) and the total number of net positive charges (p_(t)) is as follows:

TABLE 4 Aromatic groups and net positive charges (2a ≤ p_(t) + 1 or a =p_(t) = 1) (p_(t)) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20(a) 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10

In another embodiment, the number of aromatic groups (a) and the totalnumber of net positive charges (p_(t)) are equal.

Carboxyl groups, especially the terminal carboxyl group of a C-terminalamino acid, are suitably amidated with, for example, ammonia to form theC-terminal amide. Alternatively, the terminal carboxyl group of theC-terminal amino acid may be amidated with any primary or secondaryamine. The primary or secondary amine may, for example, be an alkyl,especially a branched or unbranched C₁-C₄ alkyl, or an aryl amine.Accordingly, the amino acid at the C-terminus of the peptide may beconverted to an amido, N-methylamido, N-ethylamido, N,N-dimethylamido,N,N-diethylamido, N-methyl-N-ethylamido, N-phenylamido orN-phenyl-N-ethylamido group. The free carboxylate groups of theasparagine, glutamine, aspartic acid, and glutamic acid residues notoccurring at the C-terminus of the aromatic-cationic peptides may alsobe amidated wherever they occur within the peptide. The amidation atthese internal positions may be with ammonia or any of the primary orsecondary amines described above.

In one embodiment, the aromatic-cationic peptide is a tripeptide havingtwo net positive charges and at least one aromatic amino acid. In aparticular embodiment, the aromatic-cationic peptide is a tripeptidehaving two net positive charges and two aromatic amino acids.

Aromatic-cationic peptides include, but are not limited to, thefollowing peptide examples:

Lys-D-Arg-Tyr-NH₂ Phe-D-Arg-His D-Tyr-Trp-Lys-NH₂ Trp-D-Lys-Tyr-Arg-NH₂Tyr-His-D-Gly-Met Phe-Arg-D-His-Asp Tyr-D-Arg-Phe-Lys-Glu-NH₂Met-Tyr-D-Lys-Phe-Arg D-His-Glu-Lys-Tyr-D-Phe-ArgLys-D-Gln-Tyr-Arg-D-Phe-Trp-NH₂ Phe-D-Arg-Lys-Trp-Tyr-D-Arg-HisGly-D-Phe-Lys-Tyr-His-D-Arg-Tyr-NH₂Va1-D-Lys-His-Tyr-D-Phe-Ser-Tyr-Arg-NH₂Trp-Lys-Phe-D-Asp-Arg-Tyr-D-His-LysLys-Trp-D-Tyr-Arg-Asn-Phe-Tyr-D-His-NH₂Thr-Gly-Tyr-Arg-D-His-Phe-Trp-D-His-LysAsp-D-Trp-Lys-Tyr-D-His-Phe-Arg- D-Gly-Lys-NH₂D-His-Lys-Tyr- D-Phe-Glu- D-Asp- D-His- D-Lys-Arg- Trp-NH₂Ala-D-Phe-D-Arg-Tyr-Lys-D-Trp-His-D-Tyr-Gly-PheTyr-D-His-Phe- D-Arg-Asp-Lys- D-Arg-His-Trp-D-His- PhePhe-Phe-D-Tyr-Arg-Glu-Asp-D-Lys-Arg-D-Arg-His-Phe- NH₂Phe-Try-Lys-D-Arg-Trp-His-D-Lys-D-Lys-Glu-Arg-D- Tyr-ThrTyr-Asp-D-Lys-Tyr-Phe- D-Lys- D-Arg-Phe-Pro-D-Tyr- His-LysGlu-Arg-D-Lys-Tyr- D-Val-Phe- D-His-Trp-Arg-D-Gly- Tyr-Arg-D-Met-NH₂Arg-D-Leu-D-Tyr-Phe-Lys-Glu- D-Lys-Arg-D-Trp-Lys- D-Phe-Tyr-D-Arg-GlyD-Glu-Asp-Lys-D-Arg-D-His-Phe-Phe-D-Val-Tyr-Arg-Tyr-D-Tyr-Arg-His-Phe-NH₂Asp-Arg-D-Phe-Cys-Phe-D-Arg-D-Lys-Tyr-Arg-D-Tyr-Trp-D-His-Tyr-D-Phe-Lys-PheHis-Tyr-D-Arg-Trp-Lys-Phe-D-Asp-Ala-Arg-Cys-D-Tyr-His-Phe-D-Lys-Tyr-His-Ser-NH₂Gly-Ala-Lys-Phe-D-Lys-Glu-Arg-Tyr-His-D-Arg-D-Arg-Asp-Tyr-Trp-D-His-Trp-His-D-Lys-AspThr-Tyr-Arg-D-Lys-Trp-Tyr-Glu-Asp-D-Lys-D-Arg-His-Phe-D-Tyr-Gly-Val-Ile-D-His-Arg-Tyr-Lys-NH₂

In one embodiment, the peptides have mu-opioid receptor agonist activity(i.e., they activate the mu-opioid receptor). Peptides, which havemu-opioid receptor agonist activity, are typically those peptides, whichhave a tyrosine residue or a tyrosine derivative at the N-terminus(i.e., the first amino acid position). Suitable derivatives of tyrosineinclude 2′-methyltyrosine (Mmt); 2′,6′-dimethyltyrosine (2′6′-Dmt);3′,5′-dimethyltyrosine (3′5′Dmt); N,2′,6′-trimethyltyrosine (Tmt); and2′-hydroxy-6′-methyltryosine (Hmt).

In one embodiment, a peptide that has mu-opioid receptor agonistactivity has the formula Tyr-D-Arg-Phe-Lys-NH₂. Tyr-D-Arg-Phe-Lys-NH₂has a net positive charge of three, contributed by the amino acidstyrosine, arginine, and lysine and has two aromatic groups contributedby the amino acids phenylalanine and tyrosine. The tyrosine ofTyr-D-Arg-Phe-Lys-NH₂ can be a modified derivative of tyrosine such asin 2′,6′-dimethyltyrosine to produce the compound having the formula2′,6′-Dmt-D-Arg-Phe-Lys-NH₂. 2′,6′-Dmt-D-Arg-Phe-Lys-NH₂ has a molecularweight of 640 and carries a net three positive charge at physiologicalpH. 2′,6′-Dmt-D-Arg-Phe-Lys-NH₂ readily penetrates the plasma membraneof several mammalian cell types in an energy-independent manner (Zhao etal., J. Pharmacol Exp Ther., 304:425-432, 2003).

Alternatively, in other instances, the aromatic-cationic peptide doesnot have mu-opioid receptor agonist activity. For example, duringlong-term treatment, such as in a chronic disease state or condition,the use of an aromatic-cationic peptide that activates the mu-opioidreceptor may be contraindicated. In these instances, the potentiallyadverse or addictive effects of the aromatic-cationic peptide maypreclude the use of an aromatic-cationic peptide that activates themu-opioid receptor in the treatment regimen of a human patient or othermammal. Potential adverse effects may include sedation, constipation andrespiratory depression. In such instances an aromatic-cationic peptidethat does not activate the mu-opioid receptor may be an appropriatetreatment. Peptides that do not have mu-opioid receptor agonist activitygenerally do not have a tyrosine residue or a derivative of tyrosine atthe N-terminus (i.e., amino acid position 1). The amino acid at theN-terminus can be any naturally occurring or non-naturally occurringamino acid other than tyrosine. In one embodiment, the amino acid at theN-terminus is phenylalanine or its derivative. Exemplary derivatives ofphenylalanine include 2′-methylphenylalanine (Mmp),2′,6′-dimethylphenylalanine (2′,6′-Dmp), N,2′,6′-trimethylphenylalanine(Tmp), and 2′-hydroxy-6′-methylphenylalanine (Hmp).

An example of an aromatic-cationic peptide that does not have mu-opioidreceptor agonist activity has the formula Phe-D-Arg-Phe-Lys-NH₂.Alternatively, the N-terminal phenylalanine can be a derivative ofphenylalanine such as 2′,6′-dimethylphenylalanine (2′6′-Dmp).Tyr-D-Arg-Phe-Lys-NH₂ containing 2′,6′-dimethylphenylalanine at aminoacid position 1 has the formula 2′,6′-Dmp-D-Arg-Phe-Lys-NH₂. In oneembodiment, the amino acid sequence of 2′,6′-Dmt-D-Arg-Phe-Lys-NH₂ isrearranged such that Dmt is not at the N-terminus. An example of such anaromatic-cationic peptide that does not have mu-opioid receptor agonistactivity has the formula D-Arg-2′6′-Dmt-Lys-Phe-NH₂.

Suitable substitution variants of the peptides listed herein includeconservative amino acid substitutions. Amino acids may be groupedaccording to their physicochemical characteristics as follows:

(a) Non-polar amino acids: Ala(A) Ser(S) Thr(T) Pro(P) Gly(G) Cys (C);

(b) Acidic amino acids: Asn(N) Asp(D) Glu(E) Gln(Q);

(c) Basic amino acids: His(H) Arg(R) Lys(K);

(d) Hydrophobic amino acids: Met(M) Leu(L) Ile(I) Val(V); and

(e) Aromatic amino acids: Phe(F) Tyr(Y) Trp(W) His (H).

Substitutions of an amino acid in a peptide by another amino acid in thesame group is referred to as a conservative substitution and maypreserve the physicochemical characteristics of the original peptide. Incontrast, substitutions of an amino acid in a peptide by another aminoacid in a different group is generally more likely to alter thecharacteristics of the original peptide.

Examples of peptides that activate mu-opioid receptors include, but arenot limited to, the aromatic-cationic peptides shown in Table 5.

TABLE 5 Peptide Analogs with Mu-Opioid Activity Amino Amino Amino AminoAcid Acid Acid Acid C-Terminal Position 1 Position 2 Position 3 Position4 Modification Tyr D-Arg Phe Lys NH₂ Tyr D-Arg Phe Orn NH₂ Tyr D-Arg PheDab NH₂ Tyr D-Arg Phe Dap NH₂ 2′6′Dmt D-Arg Phe Lys NH₂ 2′6′Dmt D-ArgPhe Lys-NH(CH₂)₂—NH-dns NH₂ 2′6′Dmt D-Arg Phe Lys-NH(CH₂)₂—NH-atn NH₂2′6′Dmt D-Arg Phe dnsLys NH₂ 2′6′Dmt D-Cit Phe Lys NH₂ 2′6′Dmt D-Cit PheAhp NH₂ 2′6′Dmt D-Arg Phe Orn NH₂ 2′6′Dmt D-Arg Phe Dab NH₂ 2′6′DmtD-Arg Phe Dap NH₂ 2′6′Dmt D-Arg Phe Ahp(2-aminoheptanoic acid) NH₂Bio-2′6′Dmt D-Arg Phe Lys NH₂ 3′5′Dmt D-Arg Phe Lys NH₂ 3′5′Dmt D-ArgPhe Orn NH₂ 3′5′Dmt D-Arg Phe Dab NH₂ 3′5′Dmt D-Arg Phe Dap NH₂ TyrD-Arg Tyr Lys NH₂ Tyr D-Arg Tyr Orn NH₂ Tyr D-Arg Tyr Dab NH₂ Tyr D-ArgTyr Dap NH₂ 2′6′Dmt D-Arg Tyr Lys NH₂ 2′6′Dmt D-Arg Tyr Orn NH₂ 2′6′DmtD-Arg Tyr Dab NH₂ 2′6′Dmt D-Arg Tyr Dap NH₂ 2′6′Dmt D-Arg 2′6′Dmt LysNH₂ 2′6′Dmt D-Arg 2′6′Dmt Orn NH₂ 2′6′Dmt D-Arg 2′6′Dmt Dab NH₂ 2′6′DmtD-Arg 2′6′Dmt Dap NH₂ 3′5′Dmt D-Arg 3′5′Dmt Arg NH₂ 3′5′Dmt D-Arg3′5′Dmt Lys NH₂ 3′5′Dmt D-Arg 3′5′Dmt Orn NH₂ 3′5′Dmt D-Arg 3′5′Dmt DabNH₂ Tyr D-Lys Phe Dap NH₂ Tyr D-Lys Phe Arg NH₂ Tyr D-Lys Phe Lys NH₂Tyr D-Lys Phe Orn NH₂ 2′6′Dmt D-Lys Phe Dab NH₂ 2′6′Dmt D-Lys Phe DapNH₂ 2′6′Dmt D-Lys Phe Arg NH₂ 2′6′Dmt D-Lys Phe Lys NH₂ 3′5′Dmt D-LysPhe Orn NH₂ 3′5′Dmt D-Lys Phe Dab NH₂ 3′5′Dmt D-Lys Phe Dap NH₂ 3′5′DmtD-Lys Phe Arg NH₂ Tyr D-Lys Tyr Lys NH₂ Tyr D-Lys Tyr Orn NH₂ Tyr D-LysTyr Dab NH₂ Tyr D-Lys Tyr Dap NH₂ 2′6′Dmt D-Lys Tyr Lys NH₂ 2′6′DmtD-Lys Tyr Orn NH₂ 2′6′Dmt D-Lys Tyr Dab NH₂ 2′6′Dmt D-Lys Tyr Dap NH₂2′6′Dmt D-Lys 2′6′Dmt Lys NH₂ 2′6′Dmt D-Lys 2′6′Dmt Orn NH₂ 2′6′DmtD-Lys 2′6′Dmt Dab NH₂ 2′6′Dmt D-Lys 2′6′Dmt Dap NH₂ 2′6′Dmt D-Arg PhednsDap NH₂ 2′6′Dmt D-Arg Phe atnDap NH₂ 2′6′Dmt D-Lys 3′5′Dmt Lys NH₂2′6′Dmt D-Lys 3′5′Dmt Orn NH₂ 2′6′Dmt D-Lys 3′5′Dmt Dab NH₂ 2′6′DmtD-Lys 3′5′Dmt Dap NH₂ Tyr D-Lys Phe Arg NH₂ Tyr D-Orn Phe Arg NH₂ TyrD-Dab Phe Arg NH₂ Tyr D-Dap Phe Arg NH₂ 2′6′Dmt D-Arg Phe Arg NH₂2′6′Dmt D-Lys Phe Arg NH₂ 2′6′Dmt D-Orn Phe Arg NH₂ 2′6′Dmt D-Dab PheArg NH₂ 3′5′Dmt D-Dap Phe Arg NH₂ 3′5′Dmt D-Arg Phe Arg NH₂ 3′5′DmtD-Lys Phe Arg NH₂ 3′5′Dmt D-Orn Phe Arg NH₂ Tyr D-Lys Tyr Arg NH₂ TyrD-Orn Tyr Arg NH₂ Tyr D-Dab Tyr Arg NH₂ Tyr D-Dap Tyr Arg NH₂ 2′6′DmtD-Arg 2′6′Dmt Arg NH₂ 2′6′Dmt D-Lys 2′6′Dmt Arg NH₂ 2′6′Dmt D-Orn2′6′Dmt Arg NH₂ 2′6′Dmt D-Dab 2′6′Dmt Arg NH₂ 3′5′Dmt D-Dap 3′5′Dmt ArgNH₂ 3′5′Dmt D-Arg 3′5′Dmt Arg NH₂ 3′5′Dmt D-Lys 3′5′Dmt Arg NH₂ 3′5′DmtD-Orn 3′5′Dmt Arg NH₂ Mmt D-Arg Phe Lys NH₂ Mmt D-Arg Phe Orn NH₂ MmtD-Arg Phe Dab NH₂ Mmt D-Arg Phe Dap NH₂ Tmt D-Arg Phe Lys NH₂ Tmt D-ArgPhe Orn NH₂ Tmt D-Arg Phe Dab NH₂ Tmt D-Arg Phe Dap NH₂ Hmt D-Arg PheLys NH₂ Hmt D-Arg Phe Orn NH₂ Hmt D-Arg Phe Dab NH₂ Hmt D-Arg Phe DapNH₂ Mmt D-Lys Phe Lys NH₂ Mmt D-Lys Phe Orn NH₂ Mmt D-Lys Phe Dab NH₂Mmt D-Lys Phe Dap NH₂ Mmt D-Lys Phe Arg NH₂ Tmt D-Lys Phe Lys NH₂ TmtD-Lys Phe Orn NH₂ Tmt D-Lys Phe Dab NH₂ Tmt D-Lys Phe Dap NH₂ Tmt D-LysPhe Arg NH₂ Hmt D-Lys Phe Lys NH₂ Hmt D-Lys Phe Orn NH₂ Hmt D-Lys PheDab NH₂ Hmt D-Lys Phe Dap NH₂ Hmt D-Lys Phe Arg NH₂ Mmt D-Lys Phe ArgNH₂ Mmt D-Orn Phe Arg NH₂ Mmt D-Dab Phe Arg NH₂ Mmt D-Dap Phe Arg NH₂Mmt D-Arg Phe Arg NH₂ Tmt D-Lys Phe Arg NH₂ Tmt D-Orn Phe Arg NH₂ TmtD-Dab Phe Arg NH₂ Tmt D-Dap Phe Arg NH₂ Tmt D-Arg Phe Arg NH₂ Hmt D-LysPhe Arg NH₂ Hmt D-Orn Phe Arg NH₂ Hmt D-Dab Phe Arg NH₂ Hmt D-Dap PheArg NH₂ Hmt D-Arg Phe Arg NH₂ Dab = diaminobutyric Dap =diaminopropionic acid Dmt = dimethyltyrosine Mmt = 2′-methyltyrosine Tmt= N,2′,6′-trimethyltyrosine Hmt = 2′-hydroxy,6′-methyltyrosine dnsDap =β-dansyl-L-α,β-diaminopropionic acid atnDap =β-anthraniloyl-L-α,β-diaminopropionic acid Bio = biotin

Examples of peptides that do not activate mu-opioid receptors include,but are not limited to, the aromatic-cationic peptides shown in Table 6.

TABLE 6 Peptide Analogs Lacking Mu-Opioid Activity Amino Amino AminoAmino Acid Acid Acid Acid C-Terminal Position 1 Position 2 Position 3Position 4 Modification D-Arg Dmt Lys Phe NH₂ D-Arg Dmt Phe Lys NH₂D-Arg Phe Lys Dmt NH₂ D-Arg Phe Dmt Lys NH₂ D-Arg Lys Dmt Phe NH₂ D-ArgLys Phe Dmt NH₂ Phe Lys Dmt D-Arg NH₂ Phe Lys D-Arg Dmt NH₂ Phe D-ArgPhe Lys NH₂ Phe D-Arg Dmt Lys NH₂ Phe D-Arg Lys Dmt NH₂ Phe Dmt D-ArgLys NH₂ Phe Dmt Lys D-Arg NH₂ Lys Phe D-Arg Dmt NH₂ Lys Phe Dmt D-ArgNH₂ Lys Dmt D-Arg Phe NH₂ Lys Dmt Phe D-Arg NH₂ Lys D-Arg Phe Dmt NH₂Lys D-Arg Dmt Phe NH₂ D-Arg Dmt D-Arg Phe NH₂ D-Arg Dmt D-Arg Dmt NH₂D-Arg Dmt D-Arg Tyr NH₂ D-Arg Dmt D-Arg Trp NH₂ Trp D-Arg Phe Lys NH₂Trp D-Arg Tyr Lys NH₂ Trp D-Arg Trp Lys NH₂ Trp D-Arg Dmt Lys NH₂ D-ArgTrp Lys Phe NH₂ D-Arg Trp Phe Lys NH₂ D-Arg Trp Lys Dmt NH₂ D-Arg TrpDmt Lys NH₂ D-Arg Lys Trp Phe NH₂ D-Arg Lys Trp Dmt NH₂ Cha D-Arg PheLys NH₂ Ala D-Arg Phe Lys NH₂ Cha = cyclohexyl alanine

The amino acids of the peptides shown in the tables above may be ineither the L- or the D-configuration.

The peptides may be synthesized by any of the methods well known in theart. Suitable methods for chemically synthesizing the protein include,for example, those described by Stuart and Young in Solid Phase PeptideSynthesis, Second Edition, Pierce Chemical Company (1984), and inMethods Enzymol., 289, Academic Press, Inc., New York (1997).

Left Ventricular Remodeling

Following myocardial infarction there is a dynamic and progressive LVremodeling that contributes to LV dilation, heart failure, and death.Within the first week of a myocardial infarction (MI) the necrotic zonethins and stretches (infarct expansion) contributing to regionaldilation of the infarct zone. This phenomenon increases LV wall stress,thus, increasing oxygen demand. To help compensate for the loss ofmyocardium and reduced stroke volume, the LV develops global dilationand the non-infarcted wall of the LV develops eccentric hypertrophywhereby sarcomeres are added on in a circumferential or lengthwisefashion. As the ventricle dilates this process initially helps tocompensate for reduced stroke volume, but eventually progressivedilatation and hypertrophy lead to congestive heart failure. One of thestrongest predictors of death one year post MI is the volume of the leftventricle. The more dilated the left ventricle, the greater the chanceof death. Structural and functional abnormalities of the non-infarctedmyocardium and myocardium in the infarct border zone may contribute tothe LV remodeling phenomenon. Abnormalities in myocardium cell structurecan lead to reduced function of the muscles needed to support theweakened heart. In some embodiments, the aromatic-cationic peptide isadministered to the subject, chronically, post myocardial infarction.

The compositions and methods disclosed herein are not intended to belimited by the cause of myocardial infarction and/or LV remodeling. Byway of example, but not by way of limitation, myocardial infarction mayresult from hypertension; ischemic heart disease; exposure to acardiotoxic compound; myocarditis; thyroid disease; viral infection;gingivitis; drug abuse; alcohol abuse; pericarditis; atherosclerosis;vascular disease; hypertrophic cardiomyopathy; acute myocardialinfarction; left ventricular systolic dysfunction; heart failure;coronary bypass surgery; starvation; an eating disorder; or a geneticdefect.

Stabilization of SERCA2a

As discussed above, the non-infarct myocardium around the infarct, i.e.,border zone cells, change their structure to compensate for reducedstroke volume. Sarco/endoplasmic reticulum Ca²⁺-ATPase (SERCA) is acalcium ATPase-type P-ATPase. SERCA is located in the sarcoplasmicreticulum (SR) within muscle cells. Ca²⁺ ATPases transfer Ca²⁺ from thecytosol of the cell to the lumen of the SR at the expense of ATPhydrolysis during muscle relaxation. There are three major paralogs ofSERCA: SERCA1, SERCA2, and SERCA3.

During heart failure, the Ca²⁺ transport in ventricular myocytes isaltered, which causes an impaired efflux of cytosolic Ca²⁺. Decreasedexpression and activity of SERCA2a is recognized as a hallmark of heartfailure (Schwartz, R. and Yeh, T. “Weighing in on Heart Failure: TheRole of SERCA2a SUMOylation.” Nature. 477: 601-605 (2011)).Additionally, decreased expression of SERCA2a is seen after myocardialinfarction (Zarain-Herzberg et al. “Decreased expression of cardiacsarcoplasmic reticulum Ca2+-pump ATPase in congestive heart failure dueto myocardial infarction.” Dev. Mol. and Cell. Bio. 19: 285-290 (1996)).Current studies are directed at raising SERCA2a expression to protectagainst heart failure and left ventricular remodeling (Niwano et al.“Lentiviral Vector-mediated SERCA2 Gene Transfer Protects Against HeartFailure and Left Ventricular Remodeling After Myocardial Infarction inRats.” Molecular Therapy. 16(6): 1026-1032 (2008)). Restoration of SERCA2a in the border zone cells of an infarct will improve the function ofthe heart at that border zone (regional improvement in function).Additionally, restoration of SERCA2a in the border zone cells willprevent the stretching and thinning of the myocardial infarction (e.g.,provide for improved regions function), and will also prevent or reduceleft ventricular remodeling and improve global left ventricularfunction.

In some embodiments, treatment with an aromatic-cationic peptide, suchas, e.g., D-Arg-2′6′-Dmt-Lys-Phe-NH₂, increases SERCA2a expression in asubject in need thereof. In some embodiments, the increase of SERCA2aexpression results in a decrease in LV remodeling and improves LVfunction.

Improvement in Cardiac Function

In some embodiments, the stabilization (increase) of SERCA2a expressionthrough treatment with an aromatic-cationic peptide, such as, e.g.,D-Arg-2′6′-Dmt-Lys-Phe-NH₂, improves the cardiac function of the leftventricle after myocardial infarction. Improvement of LV functionincludes, but is not limited to, reduced LV volume, improved LVfractional shortening, improved LV ejection fraction, reduced infarctexpansion, improved hemodynamics, and reduced lung volumes. In someembodiments, administration of an aromatic-cationic peptide, such as,e.g., D-Arg-2′6′-Dmt-Lys-Phe-NH₂, results in an increase in SERCA2aexpression, and results in a reduced risk of death and/or heart failurein a subject at risk.

In some embodiments, stabilization of SERCA2a expression throughtreatment with an aromatic-catoinic peptide, such asD-Arg-2′6′-Dmt-Lys-Phe-NH₂, reduces scarring in the left ventricle postinfarction. Reduction in scarring includes, but is not limited to,reduced scar circumference, reduced scar thickness, reduced septumthickness, and a reduced expansion index (which is expressed as: LVcavity area/total LV area×septum thickness/scar thickness).

Prophylactic and Therapeutic Uses of Aromatic-Cationic Peptides.

General.

The aromatic-cationic peptides described herein are useful to prevent ortreat disease. Specifically, the disclosure provides for bothprophylactic and therapeutic methods of treating a subject having or atrisk of (susceptible to) LV remodeling by administering anaromatic-cationic peptide such as an aromatic-cationic peptide, such asD-Arg-2′6′-Dmt-Lys-Phe-NH₂ or a pharmaceutically acceptable saltthereof, such as acetate or trifluoroacetate salt. Typically, LVremodeling causes an increase in LV end diastolic volume and LV endsystolic volume. Usually, stroke volume may initially be preserved buteventually, once heart failure occurs, it is actually reduced (i.e.,less blood flows out of the ventricle with each beat). Accordingly, thepresent methods provide for the prevention and/or treatment of LVremodeling in a subject by administering an effective amount of anaromatic-cationic peptide to a subject in need thereof.

Therapeutic Methods.

In therapeutic applications, compositions or medicaments areadministered including an aromatic-cationic peptide such asD-Arg-2′6′-Dmt-Lys-Phe-NH₂ or a pharmaceutically acceptable saltthereof, such as acetate or trifluoroacetate salt, to a subjectsuspected of, or already suffering from such a disease in an amountsufficient to cure, or at least partially arrest, the symptoms of thedisease, including its complications and intermediate pathologicalphenotypes in development of the disease. One aspect of the technologyincludes methods of stabilizing (e.g., increase) SERCA2a expression(e.g., RNA and/or protein) in a subject for therapeutic purposes. Insome embodiments, the therapeutic purpose is to treat LV remodeling. Assuch, the present technology provides methods of treating an individualafflicted with LV remodeling.

Subjects suffering from LV remodeling can be identified by any or acombination of diagnostic or prognostic assays known in the art. Forexample, typical symptoms of LV remodeling include reduced LV strokevolume, reduced LV ejection fraction, poor fractional shortening,increased infarct expansion, increased LV end diastolic and systolicvolume, poor hemodynamics, increased scar formation in LV myocardium,and increased lung volumes. Symptoms of LV remodeling also includesymptoms associated with heart failure such as, e.g., shortness ofbreath, fatigue, and swelling of the extremities. In some embodiments, a“therapeutically effective amount” of the aromatic-cationic peptidethereof, includes levels in which the physiological effects of decreasedexpression of SERCA2a, at a minimum, ameliorated. Additionally, oralternatively, in some embodiments, a therapeutically effective amountof the aromatic-cationic peptides includes levels in which thephysiological effects of LV remodeling are, at a minimum, ameliorated.

Prophylactic Methods.

In one aspect, the technology provides a method for preventing, in asubject, decreased SERCA2a expression (e.g., RNA and/or protein) byadministering to the subject an effective amount of aromatic-cationicpeptide, e.g., D-Arg-2′6′-Dmt-Lys-Phe-NH₂, or a pharmaceuticallyacceptable salt thereof such as acetate or trifluoroacetate salt, thatprevents decreased SERCA2a expression during or after myocardialinfarction. Additionally, or alternatively, in some embodiments,administration of the aromatic-cationic peptide prevents or reduces LVremodeling. In prophylactic applications, pharmaceutical compositions ormedicaments of aromatic-cationic peptides are administered to a subjectsusceptible to, or otherwise at risk of a disease or condition in anamount sufficient to eliminate or reduce the risk, lessen the severity,or delay the outset of the disease, including biochemical, histologicand/or behavioral symptoms of the disease, its complications andintermediate pathological phenotypes presenting during development ofthe disease. Administration of a prophylactic aromatic-cationic canoccur prior to the manifestation of symptoms characteristic of theaberrancy, such that a disease or disorder is prevented or,alternatively, delayed in its progression.

Determination of the Biological Effect of the Aromatic-CationicPeptide-Based Therapeutic.

In various embodiments, suitable in vitro or in vivo assays areperformed to determine the effect of a specific aromatic-cationicpeptide-based therapeutic and whether its administration is indicatedfor treatment. In various embodiments, in vitro assays can be performedwith representative animal models, to determine if a givenaromatic-cationic peptide-based therapeutic exerts the desired effect inpreventing or treating heart failure. Compounds for use in therapy canbe tested in suitable animal model systems including, but not limited torats, mice, chicken, cows, monkeys, rabbits, and the like, prior totesting in human subjects. Similarly, for in vivo testing, any of theanimal model system known in the art can be used prior to administrationto human subjects.

Modes of Administration and Effective Dosages

Any method known to those in the art for contacting a cell, organ ortissue with a peptide may be employed. Suitable methods include invitro, ex vivo, or in vivo methods. In vivo methods typically includethe administration of an aromatic-cationic peptide, such as thosedescribed above, to a mammal, suitably a human. When used in vivo fortherapy, the aromatic-cationic peptides are administered to the subjectin effective amounts (i.e., amounts that have desired therapeuticeffect). The dose and dosage regimen will depend upon the degree of theinfection in the subject, the characteristics of the particulararomatic-cationic peptide used, e.g., its therapeutic index, thesubject, and the subject's history.

The effective amount may be determined during pre-clinical trials andclinical trials by methods familiar to physicians and clinicians. Aneffective amount of a peptide useful in the methods may be administeredto a mammal in need thereof by any of a number of well-known methods foradministering pharmaceutical compounds. The peptide may be administeredsystemically or locally.

In some embodiments, the aromatic-cationic peptide may be formulated asa pharmaceutically acceptable salt. Salts derived from pharmaceuticallyacceptable inorganic bases include ammonium, calcium, copper, ferric,ferrous, lithium, magnesium, manganic, manganous, potassium, sodium, andzinc salts, and the like. Salts derived from pharmaceutically acceptableorganic bases include salts of primary, secondary and tertiary amines,including substituted amines, cyclic amines, naturally-occurring aminesand the like, such as arginine, betaine, caffeine, choline,N,N′-dibenzylethylenediamine, diethylamine, 2-diethylaminoethanol,2-dimethylaminoethanol, ethanolamine, ethylenediamine,N-ethylmorpholine, N-ethylpiperidine, glucamine, glucosamine, histidine,hydrabamine, isopropylamine, lysine, methylglucamine, morpholine,piperazine, piperadine, polyamine resins, procaine, purines,theobromine, triethylamine, trimethylamine, tripropylamine, tromethamineand the like. Salts derived from pharmaceutically acceptable inorganicacids include salts of boric, carbonic, hydrohalic (hydrobromic,hydrochloric, hydrofluoric or hydroiodic), nitric, phosphoric, sulfamicand sulfuric acids. Salts derived from pharmaceutically acceptableorganic acids include salts of aliphatic hydroxyl acids (e.g., citric,gluconic, glycolic, lactic, lactobionic, malic, and tartaric acids),aliphatic monocarboxylic acids (e.g., acetic, butyric, formic, propionicand trifluoroacetic acids), amino acids (e.g., aspartic and glutamicacids), aromatic carboxylic acids (e.g., benzoic, p-chlorobenzoic,diphenylacetic, gentisic, hippuric, and triphenylacetic acids), aromatichydroxyl acids (e.g., o-hydroxybenzoic, p-hydroxybenzoic,1-hydroxynaphthalene-2-carboxylic and 3-hydroxynaphthalene-2-carboxylicacids), ascorbic, dicarboxylic acids (e.g., fumaric, maleic, oxalic andsuccinic acids), glucuronic, mandelic, mucic, nicotinic, orotic, pamoic,pantothenic, sulfonic acids (e.g., benzenesulfonic, camphosulfonic,edisylic, ethanesulfonic, isethionic, methanesulfonic,naphthalenesulfonic, naphthalene-1,5-disulfonic,naphthalene-2,6-disulfonic and p-toluenesulfonic acids), xinafoic acid,and the like. In some embodiments, the salt is an acetate ortrifluoroacetate salt.

The aromatic-cationic peptides described herein can be incorporated intopharmaceutical compositions for administration, singly or incombination, to a subject for the treatment or prevention of a disorderdescribed herein. Such compositions typically include the active agentand a pharmaceutically acceptable carrier. Supplementary activecompounds can also be incorporated into the compositions.

Pharmaceutical compositions are typically formulated to be compatiblewith its intended route of administration. Examples of routes ofadministration include parenteral (e.g., intravenous, intradermal,intraperitoneal or subcutaneous), oral, inhalation, transdermal(topical), intraocular, iontophoretic, and transmucosal administration.Solutions or suspensions used for parenteral, intradermal, orsubcutaneous application can include the following components: a sterilediluent such as water for injection, saline solution, fixed oils,polyethylene glycols, glycerine, propylene glycol or other syntheticsolvents; antibacterial agents such as benzyl alcohol or methylparabens; antioxidants such as ascorbic acid or sodium bisulfite;chelating agents such as ethylenediaminetetraacetic acid; buffers suchas acetates, citrates or phosphates and agents for the adjustment oftonicity such as sodium chloride or dextrose. pH can be adjusted withacids or bases, such as hydrochloric acid or sodium hydroxide. Theparenteral preparation can be enclosed in ampoules, disposable syringesor multiple dose vials made of glass or plastic. For convenience of thepatient or treating physician, the dosing formulation can be provided ina kit containing all necessary equipment (e.g., vials of drug, vials ofdiluent, syringes and needles) for a treatment course (e.g., 7 days oftreatment).

Pharmaceutical compositions suitable for injectable use can includesterile aqueous solutions (where water-soluble) or dispersions andsterile powders for the extemporaneous preparation of sterile injectablesolutions or dispersion. For intravenous administration, suitablecarriers include physiological saline, bacteriostatic water, CremophorEL™ (BASF, Parsippany, N.J.) or phosphate buffered saline (PBS). In allcases, a composition for parenteral administration must be sterile andshould be fluid to the extent that easy syringability exists. It shouldbe stable under the conditions of manufacture and storage and must bepreserved against the contaminating action of microorganisms such asbacteria and fungi.

The aromatic-cationic peptide compositions can include a carrier, whichcan be a solvent or dispersion medium containing, for example, water,ethanol, polyol (for example, glycerol, propylene glycol, and liquidpolyethylene glycol, and the like), and suitable mixtures thereof. Theproper fluidity can be maintained, for example, by the use of a coatingsuch as lecithin, by the maintenance of the required particle size inthe case of dispersion and by the use of surfactants. Prevention of theaction of microorganisms can be achieved by various antibacterial andantifungal agents, for example, parabens, chlorobutanol, phenol,ascorbic acid, thiomerasol, and the like. Glutathione and otherantioxidants can be included to prevent oxidation. In many cases, itwill be preferable to include isotonic agents, for example, sugars,polyalcohols such as mannitol, sorbitol, or sodium chloride in thecomposition. Prolonged absorption of the injectable compositions can bebrought about by including in the composition an agent that delaysabsorption, for example, aluminum monostearate or gelatin.

Sterile injectable solutions can be prepared by incorporating the activecompound in the required amount in an appropriate solvent with one or acombination of ingredients enumerated above, as required, followed byfiltered sterilization. Generally, dispersions are prepared byincorporating the active compound into a sterile vehicle, which containsa basic dispersion medium and the required other ingredients from thoseenumerated above. In the case of sterile powders for the preparation ofsterile injectable solutions, typical methods of preparation includevacuum drying and freeze drying, which can yield a powder of the activeingredient plus any additional desired ingredient from a previouslysterile-filtered solution thereof.

Oral compositions generally include an inert diluent or an ediblecarrier. For the purpose of oral therapeutic administration, the activecompound can be incorporated with excipients and used in the form oftablets, troches, or capsules, e.g., gelatin capsules. Oral compositionscan also be prepared using a fluid carrier for use as a mouthwash.Pharmaceutically compatible binding agents, and/or adjuvant materialscan be included as part of the composition. The tablets, pills,capsules, troches and the like can contain any of the followingingredients, or compounds of a similar nature: a binder such asmicrocrystalline cellulose, gum tragacanth or gelatin; an excipient suchas starch or lactose, a disintegrating agent such as alginic acid,Primogel, or corn starch; a lubricant such as magnesium stearate orSterotes; a glidant such as colloidal silicon dioxide; a sweeteningagent such as sucrose or saccharin; or a flavoring agent such aspeppermint, methyl salicylate, or orange flavoring.

For administration by inhalation, the compounds can be delivered in theform of an aerosol spray from a pressurized container or dispenser,which contains a suitable propellant, e.g., a gas such as carbondioxide, or a nebulizer. Such methods include those described in U.S.Pat. No. 6,468,798.

Systemic administration of a therapeutic compound as described hereincan also be by transmucosal or transdermal means. For transmucosal ortransdermal administration, penetrants appropriate to the barrier to bepermeated are used in the formulation. Such penetrants are generallyknown in the art, and include, for example, for transmucosaladministration, detergents, bile salts, and fusidic acid derivatives.Transmucosal administration can be accomplished through the use of nasalsprays. For transdermal administration, the active compounds areformulated into ointments, salves, gels, or creams as generally known inthe art. In one embodiment, transdermal administration may be performedmy iontophoresis.

A therapeutic aromatic-cationic protein or aromatic-cationic peptide canbe formulated in a carrier system. The carrier can be a colloidalsystem. The colloidal system can be a liposome, a phospholipid bilayervehicle. In one embodiment, the therapeutic peptide is encapsulated in aliposome while maintaining peptide integrity. As one skilled in the artwould appreciate, there are a variety of methods to prepare liposomes.See Lichtenberg et al., Methods Biochem. Anal., 33:337-462 (1988);Anselem et al., Liposome Technology, CRC Press (1993). Liposomalformulations can delay clearance and increase cellular uptake. SeeReddy, Ann. Pharmacother., 34(7-8):915-923 (2000). An active agent canalso be loaded into a particle prepared from pharmaceutically acceptableingredients including, but not limited to, soluble, insoluble,permeable, impermeable, biodegradable or gastroretentive polymers orliposomes. Such particles include, but are not limited to, e.g.,nanoparticles, biodegradable nanoparticles, microparticles,biodegradable microparticles, nanospheres, biodegradable nanospheres,microspheres, biodegradable microspheres, capsules, emulsions,liposomes, micelles, and viral vector systems.

The carrier can also be a polymer, e.g., a biodegradable, biocompatiblepolymer matrix. In one embodiment, the therapeutic peptide can beembedded in the polymer matrix, while maintaining protein integrity. Thepolymer may be natural, such as polypeptides, proteins orpolysaccharides, or synthetic, such as poly α-hydroxy acids. Examplesinclude carriers made of, e.g., collagen, fibronectin, elastin,cellulose acetate, cellulose nitrate, polysaccharide, fibrin, gelatin,and combinations thereof. In one embodiment, the polymer is poly-lacticacid (PLA) or copoly lactic/glycolic acid (PGLA). The polymeric matricescan be prepared and isolated in a variety of forms and sizes, includingmicrospheres and nanospheres. Polymer formulations can lead to prolongedduration of therapeutic effect. (See Reddy, Ann. Pharmacother.,34(7-8):915-923 (2000)). A polymer formulation for human growth hormone(hGH) has been used in clinical trials. See Kozarich and Rich, ChemicalBiology, 2:548-552 (1998).

Examples of polymer microsphere sustained release formulations aredescribed in PCT publication WO 99/15154 (Tracy et al.), U.S. Pat. Nos.5,674,534 and 5,716,644 (both to Zale et al.), PCT publication WO96/40073 (Zale et al.), and PCT publication WO 00/38651 (Shah et al.).U.S. Pat. Nos. 5,674,534 and 5,716,644 and PCT publication WO 96/40073describe a polymeric matrix containing particles of erythropoietin thatare stabilized against aggregation with a salt.

In some embodiments, therapeutic aromatic-cationic compounds areprepared with carriers that will protect the therapeutic compoundsagainst rapid elimination from the body, such as a controlled releaseformulation, including implants and microencapsulated delivery systems.Biodegradable, biocompatible polymers can be used, such as ethylenevinyl acetate, polyanhydrides, polyglycolic acid, collagen,polyorthoesters, and polylactic acid. Such formulations can be preparedusing known techniques. The carrier materials can be obtainedcommercially, e.g., from Alza Corporation and Nova Pharmaceuticals, Inc.Liposomal suspensions (including liposomes targeted to specific cellswith monoclonal antibodies to cell-specific antigens) can also be usedas pharmaceutically acceptable carriers. These can be prepared accordingto methods known to those skilled in the art, for example, as describedin U.S. Pat. No. 4,522,811.

The therapeutic compounds can also be formulated to enhanceintracellular delivery. For example, liposomal delivery systems areknown in the art, see, e.g., Chonn and Cullis, “Recent Advances inLiposome Drug Delivery Systems,” Current Opinion in Biotechnology6:698-708 (1995); Weiner, “Liposomes for Protein Delivery: SelectingManufacture and Development Processes,” Immunomethods, 4(3):201-9(1994); and Gregoriadis, “Engineering Liposomes for Drug Delivery:Progress and Problems,” Trends Biotechnol., 13(12):527-37 (1995).Mizguchi et al., Cancer Lett., 100:63-69 (1996), describes the use offusogenic liposomes to deliver a protein to cells both in vivo and invitro.

Dosage, toxicity and therapeutic efficacy of the therapeutic agents canbe determined by standard pharmaceutical procedures in cell cultures orexperimental animals, e.g., for determining the LD50 (the dose lethal to50% of the population) and the ED50 (the dose therapeutically effectivein 50% of the population). The dose ratio between toxic and therapeuticeffects is the therapeutic index and it can be expressed as the ratioLD50/ED50. Compounds, which exhibit high therapeutic indices, arepreferred. While compounds that exhibit toxic side effects may be used,care should be taken to design a delivery system that targets suchcompounds to the site of affected tissue in order to minimize potentialdamage to uninfected cells and, thereby, reduce side effects.

The data obtained from the cell culture assays and animal studies can beused in formulating a range of dosage for use in humans. The dosage ofsuch compounds lies preferably within a range of circulatingconcentrations that include the ED50 with little or no toxicity. Thedosage may vary within this range depending upon the dosage formemployed and the route of administration utilized. For any compound usedin the methods, the therapeutically effective dose can be estimatedinitially from cell culture assays. A dose can be formulated in animalmodels to achieve a circulating plasma concentration range that includesthe IC50 (i.e., the concentration of the test compound which achieves ahalf-maximal inhibition of symptoms) as determined in cell culture. Suchinformation can be used to more accurately determine useful doses inhumans. Levels in plasma may be measured, for example, by highperformance liquid chromatography.

Typically, an effective amount of the aromatic-cationic peptides,sufficient for achieving a therapeutic or prophylactic effect, rangefrom about 0.000001 mg per kilogram body weight per day to about 10,000mg per kilogram body weight per day. Suitably, the dosage ranges arefrom about 0.0001 mg per kilogram body weight per day to about 100 mgper kilogram body weight per day. For example dosages can be 1 mg/kgbody weight or 10 mg/kg body weight every day, every two days or everythree days or within the range of 1-10 mg/kg every week, every two weeksor every three weeks. In one embodiment, a single dosage of peptideranges from 0.001-10,000 micrograms per kg body weight. In oneembodiment, aromatic-cationic peptide concentrations in a carrier rangefrom 0.2 to 2000 micrograms per delivered milliliter. An exemplarytreatment regime entails administration once per day or once a week. Intherapeutic applications, a relatively high dosage at relatively shortintervals is sometimes required until progression of the disease isreduced or terminated, and preferably until the subject shows partial orcomplete amelioration of symptoms of disease. Thereafter, the patientcan be administered a prophylactic regime.

In some embodiments, a therapeutically effective amount of anaromatic-cationic peptide may be defined as a concentration of peptideat the target tissue of 10⁻¹² to 10⁻⁶ molar, e.g., approximately 10⁻⁷molar. This concentration may be delivered by systemic doses of 0.001 to100 mg/kg or equivalent dose by body surface area. The schedule of doseswould be optimized to maintain the therapeutic concentration at thetarget tissue, most preferably by single daily or weekly administration,but also including continuous administration (e.g., parenteral infusionor transdermal application).

The skilled artisan will appreciate that certain factors may influencethe dosage and timing required to effectively treat a subject, includingbut not limited to, the severity of the disease or disorder, previoustreatments, the general health and/or age of the subject, and otherdiseases present. Moreover, treatment of a subject with atherapeutically effective amount of the therapeutic compositionsdescribed herein can include a single treatment or a series oftreatments.

The mammal treated in accordance present methods can be any mammal,including, for example, farm animals, such as sheep, pigs, cows, andhorses; pet animals, such as dogs and cats; laboratory animals, such asrats, mice and rabbits. In a preferred embodiment, the mammal is ahuman.

Combination Therapy with an Aromatic-Cationic Peptide and OtherTherapeutic Agents

In some embodiments, the aromatic-cationic peptides such asD-Arg-2′6′-Dmt-Lys-Phe-NH₂ or a pharmaceutically acceptable saltthereof, such as acetate or trifluoroacetate salt, may be combined withone or more additional agents for the prevention or treatment of heartfailure and myocardial infarction. Drug treatment for heart failuretypically involves diuretics, ACE inhibitors, digoxin (also calleddigitalis), calcium channel blockers, and beta-blockers. In mild cases,thiazide diuretics, such as hydrochlorothiazide at 25-50 mg/day orchlorothiazide at 250-500 mg/day, are useful. However, supplementalpotassium chloride may be needed, since chronic diuresis causeshypokalemis alkalosis. Moreover, thiazide diuretics usually are noteffective in patients with advanced symptoms of heart failure. Typicaldoses of ACE inhibitors include captopril at 25-50 mg/day and quinaprilat 10 mg/day.

In some embodiments, an aromatic-cationic peptide such asD-Arg-2′6′-Dmt-Lys-Phe-NH2 or a pharmaceutically acceptable saltthereof, such as acetate or trifluoroacetate salt is combined with anadrenergic beta-2 agonist. An “adrenergic beta-2 agonist” refers toadrenergic beta-2 agonists and analogues and derivatives thereof,including, for example, natural or synthetic functional variants, whichhave adrenergic beta-2 agonist biological activity, as well as fragmentsof an adrenergic beta-2 agonist having adrenergic beta-2 agonistbiological activity. The term “adrenergic beta-2 agonist biologicalactivity” refers to activity that mimics the effects of adrenaline andnoradrenaline in a subject and which improves myocardial contractilityin a patient having heart failure. Commonly known adrenergic beta-2agonists include, but are not limited to, clenbuterol, albuterol,formeoterol, levalbuterol, metaproterenol, pirbuterol, salmeterol, andterbutaline.

In some embodiments, an aromatic-cationic peptide such asD-Arg-2′6′-Dmt-Lys-Phe-NH₂ or a pharmaceutically acceptable saltthereof, such as acetate or trifluoroacetate salt, is combined with anadrenergic beta-1 antagonist. Adrenergic beta-1 antagonists andadrenergic beta-1 blockers refer to adrenergic beta-1 antagonists andanalogues and derivatives thereof, including, for example, natural orsynthetic functional variants which have adrenergic beta-1 antagonistbiological activity, as well as fragments of an adrenergic beta-1antagonist having adrenergic beta-1 antagonist biological activity.Adrenergic beta-1 antagonist biological activity refers to activity thatblocks the effects of adrenaline on beta-receptors. Commonly knownadrenergic beta-1 antagonists include, but are not limited to,acebutolol, atenolol, betaxolol, bisoprolol, esmolol, and metoprolol.

Clenbuterol, for example, is available under numerous brand namesincluding Spiropent® (Boehinger Ingelheim), Broncodil® (Von Boch I),Broncoterol® (Quimedical PT), Cesbron® (Fidelis PT), and Clenbuter®(Biomedica Foscama). Similarly, methods of preparing adrenergic beta-1antagonists such as metoprolol and their analogues and derivatives arewell-known in the art. Metoprolol, in particular, is commerciallyavailable under the brand names Lopressor® (metoprolol tartate)manufactured by Novartis Pharmaceuticals Corporation, One Health Plaza,East Hanover, N.J. 07936-1080. Generic versions of Lopressor® are alsoavailable from Mylan Laboratories Inc., 1500 Corporate Drive, Suite 400,Canonsburg, Pa. 15317; and Watson Pharmaceuticals, Inc., 360 Mt. KembleAve. Morristown, N.J. 07962. Metoprolol is also commercially availableunder the brand name Toprol XL®, manufactured by Astra Zeneca, LP.

In some embodiments, an additional therapeutic agent is administered toa subject in combination with an aromatic cationic peptide, such that asynergistic therapeutic effect is produced. Therefore, lower doses ofone or both of the therapeutic agents may be used in treating LVremodeling, resulting in increased therapeutic efficacy and decreasedside-effects.

In any case, the multiple therapeutic agents may be administered in anyorder or even simultaneously. If simultaneously, the multipletherapeutic agents may be provided in a single, unified form, or inmultiple forms (by way of example only, either as a single pill or astwo separate pills). One of the therapeutic agents may be given inmultiple doses, or both may be given as multiple doses. If notsimultaneous, the timing between the multiple doses may vary from morethan zero weeks to less than four weeks. In addition, the combinationmethods, compositions and formulations are not to be limited to the useof only two agents.

EXAMPLES Example 1: D-Arg-2′6′-Dmt-Lys-Phe-NH₂ AdministeredPost-Myocardial Infarction Increases SERCA2a Expression

The purpose of this study was to explore the effects ofD-Arg-2′6′-Dmt-Lys-Phe-NH₂ on SERCA2a expression post-myocardialinfarction.

Methods

Rats were anesthetized, ventilated, and a thoracotomy performed in theleft 4^(th) intercostal space. Temperature was maintained at 36° C. byplacing the rats on a heating pad during the procedure. The pericardiumwas excised and the proximal left coronary artery isolated andpermanently occluded with a suture. Coronary artery occlusion wasconfirmed by cyanosis and akinesis of the anterior wall of theventricle. The chest was closed, air evacuated, and the rats allowed torecover. Analgesia was administered per the veterinarian. Anechocardiogram was obtained at approximately 15 minutes post coronaryartery occlusion. At 2 hours rats were randomized to receive chronicdaily D-Arg-2′6′-Dmt-Lys-Phe-NH₂ (delivered subcutaneously by an AlzetOsmotic Pump—3 mg/kg/day, n=7), water (n=7), sham operation (normalnon-infarct hearts, n=7). The Osmotic Pump delivered approximately 0.15μl/hr for 6 weeks (model 2006; 200 μl). The Alzat pump was implantedsubcutaneously between the shoulder blades while the rat was stillanesthetized.

After 6 weeks, heart samples were collected from shams, border zonecells of water-treated infarcted hearts (MI/BZ) andD-Arg-2′6′-Dmt-Lys-Phe-NH₂-treated hearts (MI/BZ+AP), and remotenoninfarcted area cells of water-treated hearts (MI/R) and ofD-Arg-2′6′-Dmt-Lys-Phe-NH₂-treated hearts (MI/R+AP).

All data were normalized to β-actin and presented relative to the shamgroup.

Results

qRT-PCR analysis showed that SERCA2a expression was decreased by 41%(p<0.05) in the MI/BZ group vs. sham. FIG. 1. Treatment withD-Arg-2′6′-Dmt-Lys-Phe-NH₂ restored SERCA2a expression to near normallevels in the MI/BZ+AP group. FIG. 1. There were no significantdifferences in the nonischemic remote area (MI/R).

These results show that aromatic-cationic peptides of the presenttechnology, such as D-Arg-2′6′-Dmt-Lys-Phe-NH₂, or a pharmaceuticallyacceptable salt thereof, such as acetate or trifluoroacetate salt, areuseful in the prevention and treatment of diseases and conditionsassociated with aberrant SERCA2a gene expression and/or levels. Theseresults show that aromatic-cationic peptides of the present technology,such as D-Arg-2′6′-Dmt-Lys-Phe-NH₂, or a pharmaceutically acceptablesalt thereof, such as acetate or trifluoroacetate salt, are useful inincreasing SERCA2a gene expression levels and/or protein levels, and fortreating or ameliorating the signs and symptoms of left ventricularremodeling.

Example 2: D-Arg-2′6′-Dmt-Lys-Phe-NH₂ Administered Post-MyocardialInfarction Improved LV Function

This study demonstrates that chronic therapy withD-Arg-2′6′-Dmt-Lys-Phe-NH₂, begun at 2 hours post induction of heartfailure by a transmural, non reperfused infarct in the rat, can improveoutcome. Since D-Arg-2′6′-Dmt-Lys-Phe-NH₂ treatment started at two hoursafter permanent coronary occlusion, any benefit would be independent ofphenomena such as no-reflow reduction. Two hours after coronaryocclusion, all or nearly all cells destined to die due to ischemicnecrosis have died in the rat model. This study measured the ability ofD-Arg-2′6′-Dmt-Lys-Phe-NH₂ to reduce LV volumes, improve fractionalshortening and ejection fraction, reduce infarct expansion, improvesurvival, improve hemodynamics, and reduce lung volumes.

Methods

Rats were anesthetized, ventilated, and a thoracotomy performed in theleft 4^(th) intercostal space. Temperature was maintained at 36° C. byplacing the rats on a heating pad during the procedure. The pericardiumwas excised and the proximal left coronary artery isolated andpermanently occluded with a suture. Coronary artery occlusion wasconfirmed by cyanosis and akinesis of the anterior wall of theventricle. The chest was closed, air evacuated, and the rats allowed torecover. Analgesia was administered per the veterinarian. Anechocardiogram was obtained at approximately 15 minutes post coronaryartery occlusion. At 2 hours rats were randomized to receive chronicdaily D-Arg-2′6′-Dmt-Lys-Phe-NH₂ (delivered subcutaneously by an AlzetOsmotic Pump—3 mg/kg/day) or water. The Osmotic Pump deliveredapproximately 0.15 μl/hr for 6 weeks (model 2006; 200 μl). The Alzatpump was implanted subcutaneously between the shoulder blades while therat was still anesthetized. After 6 weeks the rats were re-anesthetized,weighed, and a second echocardiogram was obtained under anesthesia. Cutdowns were performed to isolate the carotid artery and jugular vein.Heart rate and blood pressure were measured. A Millar catheter wasinserted into the left ventricle and LV systolic pressure, LV enddiastolic pressure, +dP/dt, and −dP/dt were measured. A leftventriculogram was performed using IV fluoroscopic contrast in order todetermine LV stroke volume and ejection fraction. Under deep anesthesia,the heart was excised, weighed, and pressure fixed at 11 mmHg withformalin. The lungs were also excised and weighed. Postmortem LV volumewas measured by filling the LV cavity with fluid and measuring the totalfluid. The hearts were sliced into four transverse sections andhistologic slides were prepared and stained with hematoxylin and eosinand with picrosirius red, which stains collagen. Quantitative histologicanalysis included: total circumference, scar circumference,non-infarcted wall circumference, total LV area, total LV cavity area,LV wall thickness (at several points), non-infarcted wall thickness;myocardial infarct expansion index.

Statistical Analysis

All data is reported as means±SEM. Values between groups were comparedby Student t-test. P is significant at p<0.05 level.

Results

A total of 83 rats were involved in this study. Nine rats died within 2hours after coronary occlusion (before treatment withD-Arg-2′6′-Dmt-Lys-Phe-NH or water). Seventy-four rats were randomizedto receive D-Arg-2′6′-Dmt-Lys-Phe-NH₂ or water, and no rats died duringthe following 6 weeks treatment. Twenty rat hearts (10 in each group)were harvested for assessment of gene expression study. Fifty-four ratswere used for assessment of cardiac function and post-infarct remodelingstudy.

LV Fractional Shortening by Echocardiography

The left ventricular fractional shortening (LVFS) at baseline beforecoronary occlusion was similar between the water group (44.0±1.3%) andD-Arg-2′6′-Dmt-Lys-Phe-NH₂ group (44.5±1.1%, p=0.78) (FIG. 2A). At 15minutes after coronary occlusion, LVFS remained similar between the 2groups (42.7±1.6 in water group and 45±1.8 in D-Arg-2′6′-Dmt-Lys-Phe-NH₂group, p=0.36) (LVFS did not decreased at 15 minutes probably because ofhypercontractility in the non-ischemic myocardium) (FIG. 2B).

At 6 weeks after treatment, the LVFS fell versus baseline but wassignificantly higher in the D-Arg-2′6′-Dmt-Lys-Phe-NH₂ group (28.8±1.7%)than in the water group (23.8±1.8%, p=0.047) (FIG. 2C).

LV Stroke Volume and Ejection Fraction by LV Ventriculography

At 6 weeks after treatment, there was significantly higher LV strokevolume (0.257±0.008 ml) in the D-Arg-2′6′-Dmt-Lys-Phe-NH₂-treated groupcompared to the water group (0.231±0.008, p=0.029) (FIG. 3A).Additionally, there was a significantly higher LV ejection fraction(55.3±1.4%) in the D-Arg-2′6′-Dmt-Lys-Phe-NH₂-treated group compared tothe water group (49.3±1.4%, p=0.005) (FIG. 3B).

Hemodynamics

No significant differences were noted in heart rate, systolic anddiastolic blood pressure between the two groups at 6 weeks aftertreatment (Table 7). The LV positive/negative dp/dt, end systolic leftventricular pressure, end diastolic left ventricular pressure; Tau(Weiss) and Tau (Glantz) were comparable between the two groups (Table8). There was a trend for lower minimum left ventricular pressure in theD-Arg-2′6′-Dmt-Lys-Phe-NH₂ group (0.64±0.55 mmHg) compared to watergroup (2.23±0.70 mmHg, p=0.082) (Table 8).

TABLE 7 Heart rate and blood pressure at 6 weeks after treatment HeartSystolic BP Diastolic BP Mean BP Group Rate (mmHg) (mmHg) (mmHg) Water219 ± 6 124 ± 5 90 ± 3 101 ± 4 (n = 26) D-Arg-2′6′- 209 ± 5 114 ± 4 85 ±2  94 ± 3 Dmt-Lys- Phe-NH₂ (n = 28) t-test 0.23 0.15 0.13 0.12

TABLE 8 Left ventricle hemodynamics at 6 weeks after treatment Tau TauGroup +dp/dt −dp/dt Pes Ped Pmin Weiss Glantz W 5766 ± 3934 ± 113 ± 7.82± 2.23 ± 15.2 ± 23.6 ± 0.8 268 184 5 1.08 0.70 0.4 P 5668 ± 3639 ± 105 ±5.63 ± 0.64 ± 14.6 ± 24.6 ± 0.9 161 147 3 0.84 0.55 0.6 t-test 0.76 0.220.17 0.12 0.082 0.42 0.43 W = water (n = 26) P =D-Arg-2′6′-Dmt-Lys-Phe-NH₂ (n = 28) Post-mortem LV volumes

There was a significant lower post-mortem LV volume in theD-Arg-2′6′-Dmt-Lys-Phe-NH₂-treated group compared to the water groupwhen the LV volume standardized by heart weight (0.72±0.02 inD-Arg-2′6′-Dmt-Lys-Phe-NH₂ group vs 0.79±0.08 in water group; p=0.0019)(Table 9; FIG. 4).

TABLE 9 Heart weight and post-mortem LV volume Heart LV volume LVvolume/heart Group weight (g) (ml) weight Water 0.712 ± 0.064 0.561 ±0.065 0.79 ± 0.08 (n = 26) D-Arg-2′6′- 0.724 ± 0.011 0.519 ± 0.019 0.72± 0.02 Dmt-Lys- Phe-NH₂ (n = 28) t-test 0.588 0.177 0.019

Scar Circumference, Scar Thickness, and Expansion Index

At 6 weeks after treatment, histological analysis revealed that the LVnon-scar circumference was significantly longer in theD-Arg-2′6′-Dmt-Lys-Phe-NH₂ group (15.4±0.4 mm) compared to the watergroup (13.7±0.0.6 mm, p=0.02) (FIG. 5A). Additionally, the scarcircumference was significantly smaller in theD-Arg-2′6′-Dmt-Lys-Phe-NH₂ group (9.9±0.6 mm) compared to the watergroup (12.1±0.7%, p=0.025) (FIG. 5B). The data also showed that the scarcircumference, expressed as percentage of total LV circumference, wassignificantly smaller in the D-Arg-2′6′-Dmt-Lys-Phe-NH₂ group(39.7±2.2%) compared to the water group (47.4±0.03%, p=0.024) (Table 10;FIG. 5C). The scar thickness, septum thickness and expansion indexexpressed as: [LV cavity area/Total LV area×Septum thickness/Scarthickness], were comparable between the two groups (Table 10).

TABLE 10 Effects of D-Arg-2′6′-Dmt-Lys-Phe-NH₂ on scarring Scar cir-Scar Septum cumference thickness thickness Expansion Group (%) (mm) (mm)index Water 47.4 ± 0.03 0.519 ± 0.019 1.43 ± 0.05 1.75 ± 0.09 (n = 26)D-Arg-2′6′- 39.7 ± 2.2  0.504 ± 0.039 1.45 ± 0.03 1.67 ± 0.12 Dmt-Lys-Phe-NH₂ (n = 28) t-test 0.024 0.37 0.68 0.57

Lung Weights (a Measure of Fluid Overload)

The lung dry and wet weight was measured, and the ratio of dry/wet wassimilar in the two groups.

The data demonstrated that chronic therapy withD-Arg-2′6′-Dmt-Lys-Phe-NH₂, begun at 2 hours post induction ofmyocardial infarction by ligation left coronary artery in the rat,improved cardiac function and prevented post-myocardial infarctionremodeling at 6 weeks after treatment. D-Arg-2′6′-Dmt-Lys-Phe-NH₂reduced scar circumference without increasing scar thickness, aphenomenon previously not observed with other therapies.

These results show that aromatic-cationic peptides of the presenttechnology, such as D-Arg-2′6′-Dmt-Lys-Phe-NH₂, or a pharmaceuticallyacceptable salt thereof, such as acetate or trifluoroacetate salt, areuseful in the prevention of LV remodeling and improvement of LVfunction. In particular, these results show that aromatic-cationicpeptides of the present technology, such as D-Arg-2′6′-Dmt-Lys-Phe-NH₂,or a pharmaceutically acceptable salt thereof, such as acetate ortrifluoroacetate salt, are useful to improve cardiac function postmyocardial infarction, to prevent and/or ameliorate the characteristics,signs and symptoms of left ventricular remodeling, and to improve LVfunction.

Example 3. Effects of D-Arg-2′6′-Dmt-Lys-Phe-NH₂ on Post-InfarctionRemodeling and Cardiac Function in a Rodent Model of Heart Failure

In this study, D-Arg-2′6′-Dmt-Lys-Phe-NH₂ was tested to see if it wouldimprove cardiac function and result in beneficial mitochondrial geneexpression in a post-infarct model of heart failure.

Methods

Rats underwent the permanent coronary artery ligation, as described inExample 2. The rats were split into two groups and treated for six weekswith either 3 mg/kg/day of D-Arg-2′6′-Dmt-Lys-Phe-NH₂ or 0.9% NaCl(saline) continuously through mini-osmotic pumps, which were implantedinto each animal.

After the six week period, LV function was assessed withechocardiography. Additionally, the hearts were excised and the hearttissue analyzed for LV chamber volume using tetrazolium salt staining.Heart tissue in the border zone and remote areas around the infarct werealso harvested and underwent gene array analysis to determine theexpression levels of genes involved in mitochondrial metabolism.

Results

FIG. 6 shows that treatment with D-Arg-2′6′-Dmt-Lys-Phe-NH₂ led to adecrease in LV volume/heart weight.

The data shows that chronic treatment with D-Arg-2′6′-Dmt-Lys-Phe-NH₂reduced LV dilation in a post-infarction model of heart failure.

These results show that aromatic-cationic peptides of the presenttechnology, such as D-Arg-2′6′-Dmt-Lys-Phe-NH₂, or a pharmaceuticallyacceptable salt thereof, such as acetate or trifluoroacetate salt, areuseful in the prevention and treatment of diseases and conditionsassociated with heart failure and LV remodeling. In particular, theseresults show that aromatic-cationic peptides of the present technology,such as D-Arg-2′6′-Dmt-Lys-Phe-NH₂, or a pharmaceutically acceptablesalt thereof, such as acetate or trifluoroacetate salt, are useful indecreasing or preventing an increase in LV volume/heart weight, andreduce LV dilation post myocardial infarction.

EQUIVALENTS

The present technology is not to be limited in terms of the particularembodiments described in this application, which are intended as singleillustrations of individual aspects of the technology. Manymodifications and variations of this technology can be made withoutdeparting from its spirit and scope, as will be apparent to thoseskilled in the art. Functionally equivalent methods and apparatuseswithin the scope of the technology, in addition to those enumeratedherein, will be apparent to those skilled in the art from the foregoingdescriptions. Such modifications and variations are intended to fallwithin the scope of the appended claims. The present technology is to belimited only by the terms of the appended claims, along with the fullscope of equivalents to which such claims are entitled. It is to beunderstood that this technology is not limited to particular methods,reagents, compounds compositions or biological systems, which can, ofcourse, vary. It is also to be understood that the terminology usedherein is for the purpose of describing particular embodiments only, andis not intended to be limiting.

In addition, where features or aspects of the disclosure are describedin terms of Markush groups, those skilled in the art will recognize thatthe disclosure is also thereby described in terms of any individualmember or subgroup of members of the Markush group.

As will be understood by one skilled in the art, for any and allpurposes, particularly in terms of providing a written description, allranges disclosed herein also encompass any and all possible subrangesand combinations of subranges thereof. Any listed range can be easilyrecognized as sufficiently describing and enabling the same range beingbroken down into at least equal halves, thirds, quarters, fifths,tenths, etc. As a non-limiting example, each range discussed herein canbe readily broken down into a lower third, middle third and upper third,etc. As will also be understood by one skilled in the art all languagesuch as “up to,” “at least,” “greater than,” “less than,” and the like,include the number recited and refer to ranges which can be subsequentlybroken down into subranges as discussed above. Finally, as will beunderstood by one skilled in the art, a range includes each individualmember. Thus, for example, a group having 1-3 cells refers to groupshaving 1, 2, or 3 cells. Similarly, a group having 1-5 cells refers togroups having 1, 2, 3, 4, or 5 cells, and so forth.

All patents, patent applications, provisional applications, andpublications referred to or cited herein are incorporated by referencein their entirety, including all figures and tables, to the extent theyare not inconsistent with the explicit teachings of this specification.

Other embodiments are set forth within the following claims.

What is claimed is:
 1. A method for increasing SERCA2a expression in amammalian subject in need thereof, comprising administering to themammalian subject a therapeutically effective amount anaromatic-cationic peptide, wherein the aromatic-cationic peptidecomprises D-Arg-2′6′-Dmt-Lys-Phe-NH₂, or a pharmaceutically acceptablesalt thereof.
 2. The method of claim 1, wherein the subject has suffereda myocardial infarction.
 3. The method of claim 2, wherein themyocardial infarction results from hypertension; ischemic heart disease;exposure to a cardiotoxic compound; myocarditis; thyroid disease; viralinfection; gingivitis; drug abuse; alcohol abuse; pericarditis;atherosclerosis; vascular disease; hypertrophic cardiomyopathy; acutemyocardial infarction; left ventricular systolic dysfunction; coronarybypass surgery; starvation; an eating disorder; or a genetic defect. 4.The method of claim 1, wherein the aromatic-cationic peptide isadministered about 0.5 hours to 4 hours after myocardial infarction. 5.The method of claim 1, wherein the increase of SERCA2a expressionprevents, ameliorates, or treats LV remodeling.
 6. The method of claim1, wherein the increase of SERCA2a expression increases LV functioncompared to a control subject not administered the aromatic-cationicpeptide.
 7. The method of claim 6, wherein increased LV function isdetermined by one or more physiological measures factors from the groupconsisting of reduced LV stroke volume, improved LV ejection fraction,improved fractional shortening, reduced infarct expansion, improvedhemodynamics, and reduced lung volumes.
 8. The method of claim 1,wherein the subject is a human.
 9. The method of claim 1, wherein thepeptide is administered orally, topically, systemically, intravenously,subcutaneously, intraperitoneally, or intramuscularly.
 10. The method ofclaim 1, further comprising separately, sequentially or simultaneouslyadministering a cardiovascular agent to the subject.
 11. The method ofclaim 10, wherein the cardiovascular agent is selected from the groupconsisting of: an anti-arrhthymia agent, a vasodilator, an anti-anginalagent, a corticosteroid, a cardioglycoside, a diuretic, a sedative, anangiotensin converting enzyme (ACE) inhibitor, an angiotensin IIantagonist, a thrombolytic agent, a calcium channel blocker, athroboxane receptor antagonist, a radical scavenger, an anti-plateletdrug, a β-adrenaline receptor blocking drug, α-receptor blocking drug, asympathetic nerve inhibitor, a digitalis formulation, an inotrope,captopril, and an antihyperlipidemic drug.